The focus of this blog is on the wonders of government-run health-care everywhere but I also note the damage done to private medicine by a legal system that supports predatory litigation.

The long-established socialized medicine systems in Britain and Australia are a particularly relevant warning about where such systems end up.

Posts by John J. Ray (M.A.; Ph.D.)

Monday, November 02, 2009

Thousands of British women misled into breast cancer surgery by NHS

THE government has been forced to rewrite its advice on breast cancer screening after research showed that thousands of women have been misled into having unnecessary surgery. Women invited for screening by the National Health Service will be told that some of the cancers detected will be dormant and may never spread to other tissue.

Research published this year showed that for every 2,000 women screened regularly for a decade, one life would be saved but 10 healthy women would be treated unnecessarily. The information now given to women has been criticised for advertising only the benefits and not the risks to encourage women to be screened.

Joan Austoker, author of the NHS leaflets, admitted it had been a mistake to withhold information about potentially unnecessary treatment for a type of breast cancer called ductal carcinoma in situ. Austoker, director of the primary care education research group at Oxford University, who is writing the advice by the NHS breast screening programme, said: “We want to make sure that all the risks of breast screening are referred to in appropriate detail.

“Much of the ductal carcinoma in situ diagnosed will never surface clinically. Therefore it constitutes overdiagnosis — that is, you are diagnosing something that would not have become an issue.”

Ductal carcinoma in situ accounts for 20% of the diagnoses made through screening. Less than half of the dormant cancers will progress to become invasive but 30% are treated with mastectomies. The other downsides of screening, to be described in more detail in the advice, include missing some cancers and the anxiety caused by identifying others that do not exist, so-called “false positives”.

A SICK pensioner was abandoned inside an ambulance for more than five hours after the its driver forgot about him and went home. The 65-year-old man was trapped inside the vehicle at Sharston ambulance station in Wythenshawe until he was found at 1.15am following a major police alert. The driver was supposed to take him back to his Northenden care home after he left a hospital appointment at 7pm. But it's understood that after dropping off three other patients, the driver took the vehicle back to the station and locked it up for the night when his shift ended at 8pm.

The North West Ambulance Service has launched an urgent inquiry and the driver has been suspended. Ambulance chiefs have apologised to the man, who was unhurt, in person.

The blunder has been slammed by other ambulance staff. A source said: "He was reported to police as a high risk missing person. I find it a disgrace that a member of the ambulance service can forget about a patient in the back of an ambulance and lock it up. Most staff are very annoyed about this." The kidney patient, who lives at Lee House on Longley Lane, Northenden, had attended a regular 7pm appointment at Manchester Royal Infirmary on Tuesday. Bosses at the care home said he was usually brought home by ambulance between 7pm and 7.30pm.

The man was collected from the hospital by a driver working for the patient transport service, a van-style ambulance used to take non-emergency patients to and from appointments. It is understood that three other patients were on board at the time.

The alarm was initially raised at his care home after the man failed to return home. The duty manager telephoned the hospital at 8.30pm and was told that he had already left. But by 10.30pm he still hadn't returned and the home again called the hospital, who contacted the police. Police launched an alert and he was classed as a 'high risk' missing person because of his treatment. The ambulance service said the man was found shortly after 1am in the back of the van parked at the station on Leestone Road, Sharston, which is open 24 hours a day.

The ambulance station is less than half-a-mile from the man's care home. Lee House. A spokesman refused to reveal anything further about the circumstances or say why the man wasn't taken home.

The man has now returned to the home. Police said the incident was a matter solely for the North West Ambulance Service and no criminal investigation would be launched.

Darren Hurrell, chief executive of the North West Ambulance Service, said the Trust was taking the matter 'extremely seriously' and had apologised to the family. He said: "The Trust was extremely concerned to learn of the incident which occurred on Tuesday October 27, concerning a patient left in one of our non-emergency patient transport vehicles. We are taking this extremely seriously and have offered our sincere apologies to the patient and his family. "A member of staff has been suspended with immediate effect and the Trust has commenced a full investigation has commenced. We have met with the patient and family to discuss the matter with them in greater detail and will continue to liaise closely with them throughout this process. "All possible steps will be taken to ensure that this never happens again."

It used to be said that there is no such thing as a free lunch. But when it comes to health care reform, President Obama appears to be offering up a free breakfast, lunch, dinner and bedtime snack. At the core of the president's proposal is the idea that he can provide more health care services to more people and have it cost less. A neat trick – but one that flies in the face of economic reality, not to mention common sense.

For example, the president wants to require insurance companies to cover people with pre-existing conditions, that is, people who are already sick. Doing so will cost money. And where will that money come from? Insurance companies will simply raise premiums for the rest of us.

Similarly, the president would mandate that all insurance plans provide a new government-designed minimum benefits package. In addition to the usual coverage for hospitalization, physician services and so on, all insurance plans would also have to include coverage for prescription drugs, rehabilitation services, mental health and substance-abuse treatment; preventive services and maternity, well-baby, and well-child care, as well as dental, vision, and hearing services for children under age 21. If that's not enough, he would also establish a new federal commission headed by the surgeon general, which will have the power to develop additional minimum benefit requirements. There is no limit to how extensive those future required benefits may be.

Those additional benefits may or may not help consumers, but insurers are not going to provide them for free. In fact, some—like mental health and substance-abuse treatment—can add as much as 10 to15 percent to the cost of a policy. The president would also limit the size of deductibles and co-payments and would prohibit lifetime limits on the amount of benefits that insurance companies pay.

Indeed, some estimates suggest that the president's plan could add anywhere from 75 to 95 percent overall to the cost of insurance premiums, especially for young and healthy people.

The president also wants to subsidize insurance coverage for millions of Americans, some of whom are uninsured, but millions of whom already have insurance today. The health care bills currently making their way through Congress include subsidies for families earning as much as 300 percent of the poverty level, $66,000 for a family of four. That's the main reason these plans cost $900 billion or more.

But not to worry. The president says he won't have to raise middle-class taxes to pay for all this. Health care reform will mostly pay for itself through greater efficiency, emphasis on preventive care, and electronic medical records. Of course, experts from across the political spectrum, not to mention the Congressional Budget Office, say that those measures won't come close to covering the bill's cost. Maybe that's why the House version of the health care bill contains more than $880 billion in new taxes. The slightly cheaper Senate version raises taxes by at least $357 billion, not counting the tax penalty on those who fail to comply with the bill's insurance mandate.

Of course, the president also promises that he can cut $500 billion from Medicare spending over the next 10 years without anyone getting less of anything. All he has to do is eliminate "fraud, waste, and abuse." Not to be overly cynical, but presidents have been promising to eliminate "waste, fraud, and abuse" since at least, oh, Ronald Reagan. More neutral observers acknowledge that Medicare cuts of that magnitude will inevitable mean reductions in services.

Back when he was running for president, Barack Obama used to talk about "making the tough choices" and "being honest about the challenges we face." That's all gone now. Today the president is head chef at the free lunch café.

The doctor doesn't look like much of a crusader, bent over the frail frame of 90-year-old Alberta Scott. He has a lavender stethoscope strung round his neck and some serious bedside manner at work on this stubborn nonagenarian who wants to be anywhere but where she is: in a nursing home bed, hoping to heal and get back home. "Squeeze my hand," Dr. Peter Boling prods. "Squeeze my hand. Come on. Hard!"

This is Boling's day job, providing medical care to some of Richmond's oldest and sickest patients. A geriatrician and head of general medicine at Virginia Commonwealth University Medical Center, he visits nursing home patients with a smile and an encouraging word, and he leads a team of specialists who take to the road, medical bags in hand, to see patients where and when they need it most _ in their own homes, before a crisis lands them in the ER or a nursing facility. Boling and his team make house calls.

And now he is on a mission: To convince Congress that the old-fashioned house call could be a fresh answer to the modern-day health care reform dilemma. There are house-calls programs here and there. San Diego. Boston. The Veterans Health Administration cares for thousands in their own homes, saving money by reducing unnecessary hospitalizations and emergency room visits.

But Boling wants to bring house calls to the masses _ up to 3 million of the most high-risk, high-cost Medicare patients in the country. The idea is not just cost savings, but to provide a financial incentive to persuade more doctors to return to this kind of work. It's also about improving access and providing patients the independence they so desire.

Mostly, it's about people like Alberta Scott and the questions that first came to Boling's mind when he heard she'd been admitted to an institution for treatment of a blood infection. In a few weeks, if all goes well, can she go home? If so, who will take care of her?

At 55, Boling has a vague memory of his own pediatrician standing in the kitchen of his childhood home. It's not an image many of us can conjure in an era of overcrowded ERs and specialty clinics and the type of "managed care" that often means a long wait in a sterile reception room followed by a hasty examination.

The visiting doc went out not long after the horse and buggy, as technology advanced and institutionalized health care became the norm. In 1930, house calls accounted for 40 percent of doctor-patient encounters. By 1980, that had dropped to less than 1 percent. Today, about 4,000 of the nation's 800,000-plus doctors make house calls a substantial part of their practices, although nurses and physician assistants have picked up some of the slack, the American Academy of Home Care Physicians reports.

Boling was just a young doc himself, finishing up his residency, when a mentor persuaded him to spend half his time doing clinic work, and the other half developing a house-calls program. Like most medical students today, Boling had never thought about making house calls a part of his practice. He nevertheless hung a giant map of Richmond on his office wall and began identifying patients who lived within a 15-mile radius of the downtown VCU medical center. Each home was marked on the map with colored pins, and visits were scheduled by geography _ north, south, east, west _ to maximize Boling's time. It took only a few stops, and some memorable patients, for Boling to recognize that home care made sense.

There was the stroke victim restricted to a second-floor bedroom in his home. Time and again his wife had to call an ambulance, whose crew carried him by stretcher down rickety stairs to an emergency room _ for a bloated gastrointestinal tract, high fevers and vomiting. Turns out, the patient had low blood potassium levels. Boling began drawing blood at the house and prescribed a medication that stabilized his potassium, and staved off ER visits. "It was so stark," says Boling, "the contrast between what he needed and what (the health care system was) giving him."

There was another stroke survivor, also blind and diabetic, who was being shuttled to a vascular surgery clinic to have surgeons scrape away foot ulcers. Boling began stopping by once a month, using his scalpel to do the very same work in the patient's home.

These are the types of patients Boling envisions being cared for under the proposal now pending in Congress. The so-called "Independence at Home" provision is but one small piece of the comprehensive health care reform measures being debated in the House and Senate.

Where other proposals have divided lawmakers, the house-calls idea is winning support from Republicans and Democrats alike. Perhaps because it targets the bane of the health care system: a Medicare program on the verge of insolvency and the small percentage of patients who account for the bulk of the program's costs. "This legislation offers a higher quality and more cost-effective way for these patients to get the coordinated care they need in the comfort of their own homes," says North Carolina Sen. Richard Burr, a conservative Republican.

The provision calls for the Medicare program to partner with home-based primary care teams like Boling's for a pilot project to test whether house calls would reduce preventable hospitalizations and readmissions, ER visits and duplicative diagnostic tests for high-cost, chronically ill patients. That means patients with at least two chronic conditions _ congestive heart failure, diabetes, dementia, stroke and so on _ who have been hospitalized in the past year and require assistance for at least two daily living activities, such as bathing, dressing, walking or eating. Patients with multiple chronic conditions account for some two-thirds of Medicare, the almost $500 billion federal health insurance program for those 65 and older or disabled.

Medicare officials declined to discuss the idea, but Mark McClellan, who ran Medicare under President George W. Bush, called the proposal one that "could lead to cost-savings and better outcomes" for patients. "It's definitely worth trying," said McClellan, adding that the strength of the proposal is that practitioners must demonstrate savings in their patients' medical costs in order to get a portion of that savings back from Medicare.

That might be easier said than done. Participating practitioners would have to coordinate care in a way that actually reduces all those visits to various doctors and hospitals and, McClellan said, "that's hard to implement in real-world health care."

The Department of Veterans Affairs launched its own house-calls program back in the '70s targeting an expanding population of older veterans suffering from multiple chronic conditions. There are now some 20,000 vets enrolled, and a 2002 internal study showed a 24 percent total reduction in their cost of care. Another analysis of one program in Missouri showed costs going from $45,000 per patient per year to $17,000, said Dr. Thomas Edes, who runs the VA program.

Boling and some other house-calls physicians came up with "Independence at Home" in partnership with the American Academy of Home Care Physicians. They've visited with Medicare officials to try to sell it, had sit-downs with members of Congress, urged friends to "write their congressman" to drum up support.

True believers, Boling calls these docs-turned-lobbyists. Urban cowboys in tweed jackets. People like Dr. Gresham Bayne, a former chief of emergency medicine at the Naval Regional Medical Center in San Diego who started his "Call Doctor" program in 1985, after determining that many of the folks he saw in ERs didn't need immediate physician attention. "We've never made any money, but we've never had any regrets," Bayne says of the effort.

Boling takes a "Field of Dreams" approach to the money side of things. If Medicare shared the savings, house-calls teams could recoup more expenses and pay better _ and the doctors would come.

But another challenge is persuading doctors to return to a practice that is unfamiliar now to many and looks much different in today's world than the romanticized house-calls practice of old.

Technology has certainly made the job easier. Electronic medical records are available via laptop computers. One bulky bag can carry diagnostic tools to test blood, urine and oxygen levels, a blood pressure cuff, an eye chart. Portable, digital X-ray machines are also available, as are portable EKG machines.

They may not like it, but many House liberals look ready to accept a compromise health care bill, putting Democratic leaders well on the way to delivering on President Barack Obama's call for overhaul. After claiming for months they couldn't vote for a bill without the strongest possible government-run insurance option, liberals are putting aside their disappointment over the weaker version in the legislation for a historic chance to remake America's medical system. "The current language is far weaker than what I would have preferred, and I think that is also true of the Progressive Caucus," Rep. Emanuel Cleaver, D-Mo., a member of the Congressional Black Caucus, said Friday. "But because I did not come up here to participate in gridlock and acrimony, I have told leadership that I am willing to compromise."

Obama privately told House liberals they should chalk up a win. Leaders from the Progressive, Black, Hispanic and Asian-Pacific American caucuses met at the White House Thursday evening with Obama, who listened to their concerns and praised their efforts. "He looked at us and he said, 'You guys ought to be walking around like you won because you brought back the public option,'" said Rep. Mike Honda, D-Calif. He was referring to the fact that prospects for any kind of government-run option looked grim after August's angry town halls.

House floor debate could begin late next week on the sweeping bill that extends coverage to 96 percent of Americans, imposes new requirements on individuals and employers to get insurance and provides subsidies for lower-income people.

The bill includes a new public insurance plan that would pay providers and hospitals rates negotiated by the Health and Human Services secretary. Liberals had pushed for payment rates to be tied to Medicare, which they argued would mean lower costs to consumers and the federal government. But moderates' concerns that those lower rates would hurt hospitals and other providers in their districts prevailed, even though House Speaker Nancy Pelosi, D-Calif., had backed the Medicare-based version.

In one bit of sobering news, the Congressional Budget Office estimated that only about 6 million people would sign up and that premiums for the government plan could be higher than for private coverage. The CBO says sicker people with higher costs probably would be attracted to the government plan. By comparison, 162 million people would remain covered through employer plans.

There are still concerns from moderates over the bill's cost _ $1.055 trillion over 10 years _ and long-term spending implications, and disputes to be resolved on how to block federal funding of abortions and prevent illegal immigrants from getting taxpayer-funded care. But the once-strident liberal opposition to the version of the public insurance option in the bill Pelosi released Thursday had all but disappeared 24 hours later.

It's the exact outcome Pelosi predicted in early August, infuriating progressives at the time. "Are you asking me, 'Are the progressives going to take down universal, quality, affordable health care for all Americans?' I don't think so," Pelosi said then, laughing at the question. Sure enough, they're not. "I hate to say the speaker was right, but in retrospect I guess the progressives are going to be the good soldiers on this one, one more time," said Rep. Raul Grijalva, D-Ariz., a co-chair of the Progressive Caucus.

Grijalva said progressives weren't giving up and would push to offer their preferred public insurance option as an amendment. But House leaders have indicated they won't be allowing amendments to the bill.

House liberals fear what will happen to their bill's version of the government-run plan when time comes to merge it with whatever the Senate passes.

Sen. Harry Reid, D-Nev., said earlier this week that the Senate bill would have a new federal insurance plan with negotiated payment rates. Unlike the House bill, though, states could opt out of the plan. It's not clear the proposal commands enough votes in the Senate to survive, and it could be replaced by a standby system pushed by moderates that would not go into effect until it was clear individual states were experiencing a lack of competition among private companies.

Grijalva said liberals voiced grave concerns about both the opt-out and "trigger" approaches during Thursday's White House meeting, but that Obama didn't engage on those issues.

Sen. Olympia Snowe, R-Maine, has been the leading proponent of the "trigger" approach but she told The Associated Press in an interview Friday that she didn't plan to offer it as an amendment because it didn't have the votes to prevail. Snowe is the only Republican in Congress to have supported Democrats' health care legislation, voting "yes" in the Finance Committee. But she said Friday she couldn't support Reid's current version.

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Background

Postings from Brisbane, Australia by John Ray (M.A.; Ph.D.) -- former member of the Australia-Soviet Friendship Society, former anarcho-capitalist and former member of the British Conservative party.

This blog gives a lot of attention to events in Australia and Britain -- places where there already exist systems similar to the one most likely to befall the USA if the Democrats get their way -- "Free" medical care supposedly available to all through government hospitals but with a competing private sector as well. The Canadian system is considered too Soviet to provide a likely model for the USA

TERMINOLOGY: Many of my posts concern the very instructive state of socialized medicine in Australia. Like the USA, Germany and India, Australia has a system of State governments which have substantial independence from the central (Federal) government and it is they who are mainly responsible for "free" health services. It may therefore be useful to some for me to note the standard abbreviations for the States concerned: QLD (Queensland), NSW (New South Wales), WA (Western Australia), VIC (Victoria), TAS (Tasmania), SA (South Australia).

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Conservatives do NOT object to helping the poor. Government welfare legislation in aid of the poor was in fact first introduced by conservatives -- Bismarck and Disraeli in the 19th century. What conservatives want is for the help to be delivered in a sane manner. And anyone who thinks that government bureaucracies can run hospitals well is completely out of touch with reality.

One of the oldest "free" public hospital systems in the world is that in the Australian State where I live: Queensland. It dates from 1944 (Britain's NHS began in 1948). So its advanced state of decay reveals well where the slow cancer of bureaucracy ends up. It now has three "administrative" employees for every medical employee. All those clerks are really good at curing people, I guess! Frequent bulletins on the flailing but ineffectual attempts to "fix" the system will appear here -- as well as bulletins on the dreadful things it does to patients and the long waits they endure.

On all my blogs, I express my view of what is important primarily by the readings that I select for posting. I do however on occasions add personal comments in italicized form at the beginning of an article.

I am rather pleased to report that I am a lifelong conservative. Out of intellectual curiosity, I did in my youth join organizations from right across the political spectrum so I am certainly not closed-minded and am very familiar with the full spectrum of political thinking. Nonetheless, I did not have to undergo the lurch from Left to Right that so many people undergo. At age 13 I used my pocket-money to subscribe to the "Reader's Digest" -- the main conservative organ available in small town Australia of the 1950s. I have learnt much since but am pleased and amused to note that history has since confirmed most of what I thought at that early age.

I imagine that the the RD is still sending mailouts to my 1950s address!

NOTE: The archives provided by blogspot below are rather inconvenient. They break each month up into small bits. If you want to scan whole months at a time, the backup archives will suit better. See here or here